Laserfiche WebLink
e <br /> Waste Tire SL0ey & Inspection Repo Inspection Report Number <br /> :Sa83Z. State of California <br /> CIWMB 181 IDNSurvey Form - Page 1 j 9 - JY n 6 ) 5 5 <br /> Calfomalntegrat Wase Management Board � <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> a Inspection Details <br /> TPID- ! Inspection Type (Fill one) <br /> `` <br /> Site Suffix: i ly �,' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l4 If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> (� Inspection Date <br /> City State ZIP Code Time In Time Out <br /> AM O AM <br /> Business Rep Title ` _ i <br /> 0 PM 0 PM <br /> (Vdi� >i ��t t`,��1 (fiVt.1+"I r' ✓� 1 <br /> I D'T I all� <br /> Operational Status �(r Business Role Storage Type <br /> " (Fill one only) ( " "" (Fill all that apply) (Fill all that apply) <br /> (a Active (a Generator 0 Outdoor <br /> GPS Closed <br /> , '{ <br /> Latitude EE O , ��y"NO!" <br /> n,q���r�y � � 0 Hauler 0 indoor <br /> LL�] <br /> _ 0 Inactive 0 T�c tnbr 'l <br /> O , 4 <br /> Longitude - 0 Planned 00 <br /> 0 End-Use Container <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FF m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 i 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: §. J <br /> Comments <br /> (Ie <br /> � Qc r't}~ , iu ca= f rt✓� I a�tGl f i 1141), <br /> I t;. C ( 11 <br /> Ir'E� `!!� ( ,4 ` '�l _ %t1t.Pr tti''. Jf VPGtr (I, 4' ll;!:t s!J r'�I <br /> 0 �ly � r 7 � f1ffC fvk {�� rY-�'!f fit;_, - 0 � 1 �?;� r �1 <br /> Inspection Form Included; 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone <br /> Number Inspector's Signature Phone Number_ A <br /> - - - /� M 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � r; MTP ►_ t__ Tj 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />